Destined Traveler International Trip Application

Destined Traveler International Trip Application Please read carefully and fill out completely the liability release, confidential medical form and this application. Sign them and mail them back to us with a $700 deposit payable to New Horizons Foundation, Inc./4570 Hilton Parkway, Suite 203/Colorado Springs, CO 80907.

Name of Trip:_______________________________

Date of Trip:________________ Age:_______________ Name:_______________________________________________________ _ Address:_________________________________________________ City:_______________________ State:__________ Zip:_____________ Email:______________________________________________ Phone (home):______________________________ Phone (work):_____________________________ Gender:______ Height:______ Weight:________ Occupation:_________________________________ Birthdate:___________________ Birthplace:_____________________ Citizenship:________________ Name as it appears on your passport:_______________________________________________________ Passport Number:____________________________________ Country of Issue:___________________ Do you currently have a health insurance policy? Yes__________ No_________ Name of company and policy number:_____________________________________________________ Person to notify in case of an emergency:___________________________________________________ Relationship:______________________ Address:_________________________________________________ City:_______________________ State:__________ Zip:_____________ E-mail:______________________________________________ Phone (home):______________________________ Phone (work):_____________________________ Do you have any medical conditions we should be aware of: Yes__________ No__________ If yes, please explain:___________________________________________________________________ _____________________________________________________________________________________________

How did you hear about Destined Traveler? ________________________________________________ What do you hope to gain by participating in our Thailand trip? _____________________________________________________________________________________ _____________________________________________________________________________________ Are you currently attending a church? (Name and Address) _____________________________________________________________________________________ _____________________________________________________________________________________ Do you agree with our core values? (Found on www.destinedtraveler.com) If not please explain. _____________________________________________________________________________________ Acknowledgement:

Destined Traveler  Web: www.destinedtraveler.com  Phone: (719)659-8134 Email: [email protected]

Destined Traveler International Trip Application 1.

I have read the participant agreement, release of liability and acknowledgement of risk, and understand its terms in full. 2. I have read and understand the deposit and cancelation policy and fully agree to its terms. 3. I understand that the display of misconduct, any unlawful use of drugs, acting in an unsafe manner as determined by the Destined Traveler staff may result in my removal from the trip and forfeiture of any and all payments.

Signature of Applicant: _____________________________________________ Date: ___________ Parent Signature: (If under 18 yrs. Of age) ____________________________________ Date: __________

Destined Traveler  Web: www.destinedtraveler.com  Phone: (719)659-8134 Email: [email protected]